PRAC 6645 WEEK 5 Assignment 1 : Clinical Hour and Patient Logs
PRAC 6645 WEEK 5 Assignment 1 : Clinical Hour and Patient Logs
Clinical Logs
Major Depression
Name: A.A
Age: 40 years
Diagnosis: Major depression
S: A.A is a 40-year old client that was brought today to the unit by his family for history of self-harm by cutting his hands. The client reported that he felt useless about his life, as he has not achieved anything unlike his peers. The client reported that he always has suicidal thoughts. Today in the morning, he tried to commit suicide by cutting his arm. The client also reported that his mood was highly depressed. He did not want to interact with people and often locked himself indoors. The spouse reported that A.A does not concentrate in what he does. He easily gets irritated with things. The client also reported that his energy levels were low in most of the days. He attributed the low energy to his reduced dietary intake, as he was worried that he lacked appetite. Due to the above complaints, the client was diagnosed with major depression and initiated on treatment.
O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time and events were intact. A.A denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with plans and one attempt. The judgment is intact with thoughts that are future oriented.
A: The assessment findings show that the client is experiencing severe symptoms of depression and is at risk of self-harm.
P: The client was admitted for inpatient monitoring. He was prescribed antidepress
PRAC 6645 WEEK 5 Assignment 1 Clinical Hour and Patient Logs
ants, antibiotics, and wound cleaning. He would be initiated on psychotherapy once stabilized
Major Depression
Name: E.R
Age: 29 years
Diagnosis: Major depression
S: E.R is a 29-year-old client that came to the unit today for his follow-up visit. The client was diagnosed with major depression three months ago and has been on antidepressants and psychotherapy. E.R recalled that he was diagnosed with major depression after he came to the unit with several complaints. They included persistent feelings
PRAC 6645 WEEK 5 Assignment 1 Clinical Hour and Patient Logs
of depressed mood always and lack of pleasure and interest. E.R also reported that he was finding it hard to concentrate in his social and occupational roles. He also felt worthless, as he believed that he was not performing to the expectations of the organization where he was employed. E.R had also experienced difficulties in falling asleep and maintaining sleep. There was also the complaints of suicidal thoughts and attempts. The above symptoms had affected significantly his ability to perform in his social and occupational roles. A further assessment had revealed that the symptoms were not due to a medical condition, medication, or substance use. As a result, he was diagnosed with major depression and initiated on antidepressants and psychotherapy sessions.
O: The client appeared well groomed for the session. He was alert during the assessment. He reported that his mood had improved significantly following the adopted treatments. He denied illusions, delusions, and hallucinations. His speech rate and volume were intact. He denied any recent experience of suicidal thoughts, attempts, and intentions.
A: The client is responding well to the treatment.
P: The client was advised to continue with the treatment, as positive improvement in symptoms was being reported. He was scheduled for a follow-up visit after four weeks.
Post-traumatic Stress Disorder
Name: A.N
Age: 39 years
Diagnosis: Post-traumatic stress disorder
S: A.N is a 39-year old female that came to the unit today for her first visit. She came as a referral by her physician for further assessment for what he felt that she was suffering from a mental problem. The client reported that she has been feeling low since her husband died through a road accident six months ago. The accident occurred when she was with him. A.N reported that she always experiences flashbacks and nightmares related to the accident. She also tries so much to avoid any situation that is related to the events that led to the accident, as it arouses the depressive symptoms. A.N also reported that her appetite had declined significantly over the past three months. Her engagement in the activities of the daily living was significantly reduced. A.N could not attribute to the above symptoms to any cause such as medication use, substance abuse or medical condition. As a result, she was diagnosed with post-traumatic stress disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. She did not demonstrate any abnormal behaviors. Her speech was of normal rate and volume. Her self-reported mood was depressed. She declined illusions, delusions, and hallucinations. She also declined suicidal thoughts, plans, and attempts. Her thoughts were future oriented.
A: The client is experiencing moderate symptoms of post-traumatic stress disorder.
P: The client was prescribed antidepressants. She was also initiated on group psychotherapy sessions to help her cope with the depressive symptoms. She was scheduled for the next follow-up visit after four weeks.
Insomnia
Name: E.D
Age: 34 years
Diagnosis: Insomnia
S: E.D is a 34-year old male that came to the unit today for his follow-up visit after he was diagnosed with insomnia six months ago. E.D recalled that he was diagnosed with the disorder because of his sleep-related problems. Accordingly, he was persistently experiencing an acute shortage of quality and quantity sleep. He was always finding it hard to fall asleep. He was worried that he experienced frequent awakenings whenever he found little sleep. He also noted that it was becoming hard for him to fall back after the awakenings. E.D could often find himself dozing off during the day due to the lack of enough sleep the previous days. The lack of sleep was taking a toll on him, as he was underperforming in his place of work. He was also find it hard to concentrate in his part time studies. When probed further, E.D denied any history of medication use, medical condition , or substance abuse, which could have contributed to the problem. As a result, he was diagnosed with insomnia and has been on individual psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. He was oriented to self, time, place, and events. He was alert and maintained the normal eye contact throughout the assessment. The client denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: The individual psychotherapy sessions have been effective so far. The desired treatment outcomes have been achieved.
P: The psychotherapy sessions were terminated with the consent of the client since the desired outcomes of treatment had been achieved. The client was scheduled for a follow-up visit after two months.
Binge Eating Disorder
Name: Z.P
Age: 24 years
Diagnosis: Binge eating disorder
S: Z.P is a 24-year old client that has been undergoing treatment in the unit for binge eating disorder. She was diagnosed with the disorder seven months ago and has been on individual psychotherapy sessions. Z.P reported that she was diagnosed with the disorder after she complained of abnormal eating habits. They included eating a large amount of food that is beyond those of the expected age. Z.P was worried that binge eating would affect her, as she found it difficult to control it. Z.P also reported that binge eating had affected her sense of self-identity. She was embarrassed to eat in the presence of others, as she felt that her abnormal eating of huge amount of foods were shameful. Z.P was worried that her problem was likely to predispose her to health problems such as obesity, low self-esteem, and hypertension, hence, her intention to seek professional support. Z.P was diagnosed with binge eating disorder and initiated on individual psychotherapy.
O: Z.P appeared appropriately dressed for the occasion. She was oriented to self, place, time and events. She denied any history of illusions, delusions, and hallucinations. Her level of identity was improved. She denied suicidal thoughts, attempts, and plans.
A: Psychotherapy sessions have been effective. The client reports that she now has control over her abnormal eating habits. She has sustained improved symptom improvements for the last three months.
P: The individual psychotherapy sessions were terminated with the consent of the client. The treatment objectives have been achieved. She was scheduled for a follow-up visit after three months.
Alcohol Use Disorder
Name: K.C
Age: 33 years
Diagnosis: Alcohol use disorder
S: K.C is a 33-year old client that has been undergoing treatment in the unit due to alcohol use disorder. He was diagnosed with the disorder eight months ago and has been on pharmacological treatment, psychotherapy, and participating in Alcohol Anonymous group. K.C recalled that he was diagnosed with alcohol use disorder because of his excessive alcohol intake. He was used to overconsumption of alcohol, which was becoming hard for him to control. K.C had tried to stop alcohol abuse by participating in Alcohol Anonymous group but often lost the motivation due to the severe effects of withdrawal symptoms. The client was also increasingly worried that alcohol abuse had affected significantly his binge consumption of alcohol. The alcohol abuse had affected his social and occupational health, as he was no longer productive. His wife had also threatened to leave him due to his alcohol abuse. The abuse of alcohol could not be attributed to any other cause besides peer pressure and its dependence. Therefore, he was initiated on pharmacological and psychotherapy treatments and has been participating in Alcohol Anonymous group sessions.
O: The client appeared appropriately dressed for the occasion. He was oriented to others, self, time, and events. He did not show any abnormal movements such as tremors. His mood was normal. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.
A: K.C has demonstrated optimum improvement in his symptoms. He no longer consumes alcohol. He has gained control over the withdrawal symptoms. He no longer craves for alcohol. He has been an active member of Alcohol Anonymous group sessions.
P: The use of pharmacological and psychotherapy sessions were terminated as the outcomes of the treatment had been achieved. He was advised to continue with Alcohol Anonymous group sessions. He was scheduled for a follow-up visit after one month to determine his response to treatment.
Generalized Anxiety Disorder
Name: R.O
Age: 32 years
Diagnosis: Generalized anxiety disorder
S: R.O is a 32-year old client that came to the unit for her regular follow-up visits. She was diagnosed three months ago with generalized anxiety disorder. The diagnosed was reached after she raised several complaints that related with those of the disorder. They include excessive worry and anxiety about her performance in her workplace. She also had persistent, excessive fear of an impending doom. She had reported that the excessive fear and worry were beyond her control. She reported that she often avoided stimuli that were likely to predispose her to further worries and anxiety. The accompanying symptoms that the client reported included chest pain, shortness of breath, tremors, and sweating. The psychiatric mental health nurse could not attribute the complaints to medication use, substance abuse and medical condition. R.O was worried that the symptoms were likely to affect further her social and occupational functioning if she did not get the support that she needed. As a result, she was diagnosed with generalized anxiety disorder and initiated on group psychotherapy treatment.
O: The client appeared well groomed for the occasion. She was oriented to self, others, time and events. She was alert during the assessment and maintained normal eye contact. She reported mild anxiety. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts and plans.
A: The client is responding well to psychotherapy treatment. She has developed moderate coping skills for excessive worry and anxiety.
P: The client was advised to continue with the group psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.
Psychosis
Name: C.B
Age: 43 years
Diagnosis: Psychosis
S: C.B is a 43-year old female who has been undergoing treatment in the unit due to psychosis. The client was diagnosed with the condition two months ago and has been on psychotherapy. The client came to the unit with a number of symptoms. They included difficulties in concentrating and depressed mood, sleeping too much and excessive worry. She also reported being excessively suspicious of others and hearing voices. The client’s speech was disorganized. Based on the above history, the client was diagnosed with psychosis and has been on individual psychotherapy sessions.
O: The client appeared today appropriately dressed for the occasion. She was oriented to self, place and time. The speech of the client was of normal rate and volume. She demonstrated mild anxiety during the assessment. The client denied any history of delusions, hallucinations, illusions, and suicidal thoughts, attempts or plans.
A: The client demonstrates improvement in the symptoms of psychosis when compared to the previous encounter with her. The client also demonstrated improved mood and wellbeing.
P: It was recommended that the client continue with the current individual psychotherapy sessions. The client was to be re-assessed after one month to determine his response to treatment.
Bipolar Disorder
Name: E.X
Age: 38 years
Diagnosis: Bipolar disorder
S: E.X is a 38-year-old client that came to the unit for his third follow-up visit. He was diagnosed with bipolar disorder and has been on treatment. He was diagnosed with bipolar disorder after he presented to the unit with complaints that included periods of elevated mood. The mood elevation was characterized by behaviors that that included over activity, engaging in goal-directed initiatives, excitement, euphoria and delusions. There was also the alternation of the above symptoms with periods where the client would feel to be significantly depressed. The depressive symptoms included lack of energy, too much sleeping, difficulties in concentrating and making decisions. The depressed mood could happen almost every day for a specific period such as two weeks, followed by elated mood. Further examination of the client had revealed that the symptoms were not severe to cause any impairment in the normal functioning of the client. As a result, he was diagnosed with bipolar disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. His judgment was intact. He denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.
A: The client is responding well to the adopted treatments. He also denies any side or adverse effects to the prescribed medications.
P: The client was advised to continue with the current treatments because of the improvement in symptoms and tolerability of the treatments. He was scheduled for a follow-up visit after one month.
Schizophrenia
Name: A.S
Age: 40 years
Diagnosis: Schizophrenia
S: A.S is a 40-year-old female that has been undergoing treatment in the unit due to schizophrenia. She was diagnosed with the disorder three months ago and has been on pharmacological and psychotherapy treatments. A.S recalled that she was diagnosed with schizophrenia after she started experiencing symptoms that included seeing imaginary things, hearing voices, and having a disorganized speech. The client also reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations, work, and self-care. The symptoms had persisted for more than four months. As a result, she was diagnosed with schizophrenia and initiated on treatment.
O: The client appeared well groomed for the occasion. She was oriented to space, time, events, and self. She denied any recent experience of illusions, delusions, and hallucinations. She also denied any abnormality in speech content, volume and rate. She denied suicidal thoughts, attempts, and plans. Her thought content was future oriented. She did not demonstrate any abnormal behaviors such as avoidance of eye contact and tics.
A: The treatment has been effective due to the improvement in symptoms. The client is also satisfied, as she has not experienced any side effects with the treatments.
P: The client was advised to continue with the current treatments, as the desired improvements were being achieved. She was scheduled for the next follow-up visit after four weeks.